Investigating the impact of suboptimal prescription of preoperative antiplatelets and statins on race and ethnicity-related disparities in major limb amputation.

BACKGROUND: Non-Hispanic Black and Hispanic patients with symptomatic PAD may receive different treatments than White patients with symptomatic PAD. The delivery of guideline-directed medical treatment may be a modifiable upstream driver of race and ethnicity-related disparities in outcomes such as limb amputation. The purpose of our study was to investigate the prescription of preoperative antiplatelets and statins in producing disparities in the risk of amputation following revascularization for symptomatic peripheral artery disease (PAD). METHODS: We used data from the Vascular Quality Initiative, a vascular procedure-based registry in the United States (2011-2018). We estimated the probability of preoperative antiplatelet and statin prescriptions and 1-year incidence of amputation. We then estimated the amputation risk difference between race/ethnicity groups that could be eliminated under a hypothetical intervention. RESULTS: Across 100,579 revascularizations, the 1-year amputation risk was 2.5% (2.4%, 2.6%) in White patients, 5.3% (4.9%, 5.6%) in Black patients, and 5.3% (4.7%, 5.9%) in Hispanic patients. Black (57.5%) and Hispanic patients (58.7%) were only slightly less likely than White patients (60.9%) to receive antiplatelet and statin therapy. However, the effect of antiplatelets and statins was greater in Black and Hispanic patients such that, had all patients received these medications, the estimated risk difference comparing Black to White patients would have reduced by 8.9% (-2.9%, 21.9%) and the risk difference comparing Hispanic to White patients would have been reduced by 17.6% (-0.7%, 38.6%). CONCLUSION: Even though guideline-directed care appeared evenly distributed by race/ethnicity, increasing access to such care may decrease health care disparities in major limb amputation.

Outpatient Opioid Dispensing Patterns for SC Medicaid Children 1-36 Months Old.

OBJECTIVES: We sought to identify the most common diagnostic categories linked to dispensed opioid prescriptions among children 1-36 months old and changes in patterns over the years 2000 to 2017. METHODS: This study used South Carolina's Medicaid claims data of pediatric dispensed outpatient opioid prescriptions between 2000 and 2017. The major opioid-related diagnostic category (indication) for each prescription was identified using visit primary diagnoses and the Clinical Classification System (AHRQ-CCS) software. The variables of interest were the rate of opioid prescriptions per 1,000 visits for each diagnostic category and the relative percentage of opioid prescriptions assigned to each category compared to all categories. RESULTS: Six major diagnostic categories were identified; Diseases of the respiratory system (RESP), Congenital anomalies (CONG), Injury (INJURY), Diseases of the nervous system and sense organs (NEURO), Diseases of the digestive system (GI), and Diseases of the genitourinary system (GU). The overall rate of dispensed opioid prescriptions per category declined significantly for four diagnostic categories throughout the study period, RESP by 15.13, INJURY by 8.49, NEURO by 7.33, and GI by 5.93. Two categories increased during the same time, CONG (by 9.47) and GU (by 6.98). RESP was the most prevalent category linked to a dispensed opioid prescription within 2010-2012 (almost 25%) but CONG was the most prevalent by 2014 (17.77%). CONCLUSIONS FOR PRACTICE: Among Medicaid children 1-36 months old, annual dispensed opioid prescription rates declined for most major diagnostic categories (RESP, INJURY, NEURO, and GI). Future studies should explore alternatives to current opioid dispensing practices for GU and CONG cases.

Dispensed Opioid Prescription Patterns, by Racial/Ethnic Groups, Among South Carolina Medicaid-Funded Children Experiencing Limb Fracture Injuries.

OBJECTIVE: To examine dispensed opioid prescription patterns for limb fractures across racial/ethnic groups in a pediatric population. METHODS: We used South Carolina's Medicaid claims data 2000 to 2018 for pediatric limb fracture cases (under age 19) discharged from the emergency department. The key independent variable was the child's race/ethnicity. The outcomes were: 1) whether the patient had a dispensed opioid prescription; and 2) whether dispensed opioid supply was longer than 5 days among cases with any dispensed opioid prescriptions. Logistic regression models were used to test the association between race/ethnicity and the outcomes. Covariates included age-at-service, gender, service year, and having multiple fracture injuries. RESULTS: Compared with non-Hispanic White cases (NHW), the odds of receiving dispensed opioid prescriptions were lower for cases of non-Hispanic Black (NHB) (OR = 0.73; 95% confidence interval [CI]: 0.71, 0.75), Asian (OR = 0.69; CI: 0.53, 0.90), Other/Unknown (OR = 0.86; CI: 0.80, 0.92), and Hispanic (OR = 0.84; CI: 0.79, 0.90) race/ethnicity. The odds of receiving >5 days of dispensed opioid prescription supply did not differ significantly among race/ethnic categories. CONCLUSIONS: Our study confirms previous findings that as compared to NHW, the NHB children were less likely to receive dispensed opioid prescriptions. Also, it reveals that the different minority race/ethnic groups are not homogenous in their likelihoods of receiving dispensed opioid prescriptions after a limb fracture compared to NHW, findings underreported in previous studies. Children in the Other/Unknown race/ethnicity category have prescribing patterns different from those of other minority race/ethnic groups and should be analyzed separately.

Non-Hispanic Black and Hispanic Patients Have Worse Outcomes Than White Patients Within Similar Stages of Peripheral Artery Disease.

Background Racial and ethnic disparities in outcomes following lower limb revascularization for peripheral artery disease have been ascribed to disease severity at presentation for surgery. Methods and Results We calculated 1-year risk of major adverse limb events (MALEs), major amputation, and death for patients undergoing elective revascularization for claudication or chronic limb-threatening ischemia in the Vascular Quality Initiative data (2011-2018). We report hazard ratios according to race and ethnicity using Cox (death) or Fine and Gray subdistribution hazards models (MALE and major amputation, treating death as a competing event), adjusted for patient, treatment, and anatomic factors associated with disease severity. Among 88 599 patients (age, 69 years; 37% women), 1-year risk of MALE (major amputation and death) was 12.8% (95% CI, 12.5-13.0) in 67 651 White patients, 16.5% (95% CI, 5.8-7.8) in 15 442 Black patients, and 17.2% (95% CI, 5.6-6.9) in 5506 Hispanic patients. Compared with White patients, we observed an increased hazard of poor limb outcomes among Black (MALE: 1.17; 95% CI, 1.12-1.22; amputation: 1.52; 95% CI, 1.39-1.65) and Hispanic (MALE: 1.22; 95% CI, 1.14-1.31; amputation: 1.45; 95% CI, 1.28-1.64) patients. However, Black and Hispanic patients had a hazard of death of 0.85 (95% CI, 0.79-0.91) and 0.71 (95% CI, 0.63-0.79) times the hazard among White patients, respectively. Worse limb outcomes were observed among Black and Hispanic patients across subcohorts of claudication and chronic limb-threatening ischemia. Conclusions Black and Hispanic patients undergoing infrainguinal revascularization for chronic limb-threatening ischemia and claudication had worse limb outcomes compared with White patients, even with similar disease severity at presentation. Additional investigation aimed at eliminating disparate limb outcomes is needed.